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SAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> F-O—f 0FFICE USE: II 1601 E. Hazelton Ave. , Stockton, Calif. <br /> } II Telephone: (209) 466--6781 <br /> LPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -/ V <br /> j I <br /> i THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued&_&-2 '1 <br /> (Complete In Triplicate) <br /> F Application is hereby Dade to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the'work herein described. ' This application is made in compliance with San Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A CENSUS TRACT <br /> Owner's Name —_191j'/t'l;V/� rl —�ELZ cr Phone <br /> I - T <br /> r Address v _ City=' �t.;e✓�,S,TO - <br /> Contractor Name 42d License # Phone <br /> TYPE OF WORK (Check) : LEW WELL/ DEEPEN '/ / RECONDITION / / DESTRUCTION /`7 .t <br /> J(PUMP' INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> l[Other / / <br /> iN. <br /> DISTAiNCE_-TO NEAREST: SEPTIC TAINK �p SEWER LINES)DU PIT PRIVY . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial.; Cable Tool Dia. - of Well Excavation 57 , <br /> Domestic/private >5, Dia. of Well Casing 87 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout. 7- , <br /> IR Other, Other Information ' <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type <br /> ii Type of Pump � H.P. <br /> PUMP REPLACEMENT: 'I / /.Y State Work Done <br /> PUMP 'REPAIR: I / State Work Done <br /> DPSTRUCTION OF WELL: I� Well Diameter Approximate'°Depth <br /> Ii Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Vocal Health�District <br /> and the State of California pertaining to or regulating well '-constru t on..1 Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Safi Joaquin Local Health,Distriet a <br /> WELL DRILLERS REPORT a�f .the well and notify them before putting the well in use. The above <br /> i information is true to the best of y knowledge and belief. } <br /> � r -t <br /> .ITLE <br /> SIGNED <br /> PLOT PLAN ON REVER SIDE) t (J r <br /> ii FOR DEPARTMENT USE- ONLY <br /> x I <br /> t PHASE I e 6 '. e :DATE, ! <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: V °^'' <br /> PHASE II .GROUT INSPECTION PRASE II NAL INSPECTION <br /> INSPECTION BY it DATE INSPECTION BY _ E---terD ATE Z�_ -73 <br /> A . CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E. H 1426 .I :- 5/73 --- -r„' <br />